Healthcare Provider Details

I. General information

NPI: 1912323478
Provider Name (Legal Business Name): JASON RANDALL LEWIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2014
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040A JACKSON AVE
TACOMA WA
98431-0001
US

IV. Provider business mailing address

1821 44TH STREET CT NW
GIG HARBOR WA
98335-1427
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-1110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberR6036
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License NumberR6036
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License NumberOP61442310
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: